On Brain Fitness Programs – from someone in the field

The following is a guest post by Martin Walker of Mind Sparke Brain Fitness Pro. About a month ago he and I exchanged comments, and I am delighted that he was amenable to writing this post discussing some of the research behind his company’s brain fitness program.

“I cannot teach anybody anything, I can only make them think.” – Socrates

Anyone who has read Plato’s Socratic dialogues, by choice or otherwise, knows that puzzles and mind-twisters are nothing new. Thousands of years ago, Socrates encouraged his fellow Greeks to think more logically by coaxing and goading them along elegant spirals of reasoning. I would imagine that the modern concept of neuroplasticity would confirm in Socrates the belief that the mind is malleable and trainable.

Philosophy led me to brain training. As I culled the news for interesting subjects for my philosophy blog I kept bumping up against the new science of the brain. Study after study seemed to confirm that scientists had been wrong in their model of an adult brain that didn’t change. Here were rodents learning to use rakes, and monkeys controlling robotic arms with their minds. And fMRI scans showed that these neat tricks were accompanied by changes in the animals’ brains.

But the report that converted me from an interested bystander to an active participant in what I can only describe as a revolution came from a joint study by scientists from the Universities of Michigan and Bern. With a rigorous nineteen day program of brain exercise the team showed that training one executive function – working memory – transferred to improvements in another executive function – fluid intelligence, or problem-solving ability.

These improvements weren’t just statistically interesting; the fluid intelligence of the study participants (measured by administering timed IQ test questions) increased by a whopping 40% more than that of a control group. Imagine, a training method that can make someone smarter. Less than two months later my newly formed company had a faithful version of the study’s “dual n-back” training protocol available for sale to the general public. [For more on "dual n-back" see the bottom of this page.]

Why and how does such training work? How can we be sure that the results aren’t an illusion or a temporary boost? And what can other brain training products do for us?

There’s currently a bit of a backlash against brain training from within the scientific community, attempting to mute the hubbub of enthusiasm. This is natural. There will always be inertia against radical innovations. Many scientists are habitually and commendably cautious. Skeptics tried to stop the first polio vaccine from being introduced in a national program, for instance; but the risk proved well-worth taking, saving thousands of lives while the ’safer’ vaccine was under development.

It’s long been known that working memory capacity in particular – how many things we can hold in our mind at once – plays a key role in executive function. Working memory has been correlated to IQ and academic success. Studies have also shown that a powerful working memory helps us with impulse control. The Michigan / Bern study proposed that strengthening working memory capacity may leave the brain with more processing power. This theory was borne out by the study’s results.

Although the Michigan / Bern team didn’t perform brain scans on the participants before and after working memory training, a more recent study at the Swedish Karolinska Institutet has done just that, showing that intensive working memory training increases the number of dopamine receptors in the trainee. In simpler terms, it changes the brain. The results are long lasting, and can be sustained or increased by further training.

Prior efforts to show increased intelligence with training had been unsuccessful. The “dual n-back” approach works because it’s deliberately tough on working memory, demands incredible focus, and trains two working memory functions simultaneously (visual and aural).

Not that other brain training programs don’t have merit. Offerings by the well-respected Posit Science, for instance, have been endorsed by the Australian Alzheimer’s Association, and are being used by tens of thousands of people in therapeutic and preventive programs.

Potential consumers of brain training software must keep in mind several critical aspects of a worthwhile brain training program: It should be founded on good science. It should demand focus and attention (if it’s too easy, it won’t do anything). And it should be rewarding. A sense of achievement or satisfaction will help stimulate the brain to produce new nerve cells.

Not that brain training holds the franchise on cognitive improvement and neurogenesis. Physical exercise is essential to maintaining good brain health. Regular social interaction and involvement in life-long learning help, too. And the usual advice on a healthy diet and avoidance of narcotics applies. But I firmly believe that brain training should be and will be better understood and more widely used in the future. It can help people stay mentally alert in middle and later life. It can be used to correct or mitigate learning dysfunctions. And it can improve people’s quality of life at any age by allowing them the pleasure of increased brain power.

The practical advantages that customers report from using our training program give me the most pleasure and satisfaction – the man who can spend more time with his kids because he’s more focused on his work, for instance, the high school student who is excited to take his college entrance exam because he’s feeling more confident doing the practice tests, the elderly woman who has restored her self-confidence after feeling that her memory had started to fail her. These are the kinds of benefits that change people’s lives.

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Martin Walker is a member of The British Neuroscience Association, Learning and The Brain, and MENSA. His company, Mind Evolve, LLC, publishes free information on the field of neuroscience and brain fitness, as well as one of the most effective, affordable brain training software programs available — Mind Sparke Brain Fitness Pro.

Editor’s Note:
You can learn more about the “dual n-back” process at these sites:
New Zealand’s Science Learning Hub – Student Activity – n-Back test 
Soak Your Head online open source Dual NBack Application

Mostly in Ratey’s Words

In his book SPARK, John Ratey presents the biology of what happens in the brain as a result of exercise. He described the process so clearly that I wanted to sit down and draw pictures of the brain to represent his words. (Ah, perhaps an exercise for March vacation…) He begins by stating the “the brain is flexible, or plastic in the parlance of neuroscientists–more Play-Doh than porcelain.” If you have been reading Neurons Firing, you already know this, as I’ve written extensively about brain plasticity. Play-Doh seems the perfect analogy, as it is malleable but not without initial effort at kneading and working the dough.

Ratey describes three benefits of exercise on learning.

1. Exercise “optimizes your mind-set to improve alertness, attention, and motivation.”
2. Exercise “prepares and encourages nerve cells to bind to one another, which is the cellular basis for logging in new information.”
3. Exercise “spurs the development of new nerve cells from stem cells in the hippocampus.”

He goes on to clue us in that “you can’t learn difficult material while you’re exercising at high intensity because blood is shunted away from the prefrontal cortex, and this hampers your executive function. … However, blood flow shifts back almost immediately after you finish exercising, and this is the perfect time to focus on a project that demands sharp thinking and complex analysis.”  (Stationary cyclist sculpture, Nassau Country Museum of Art)

There are chapters specific to a number of issues, including stress, anxiety, depression, attention deficit, addiction, hormonal changes, and aging. But before any of these are discussed, Ratey talks about learning. It is in this chapter that he both explains what happens in the brain as we learn and provides study after study to support what he shares. I leave you with a paragraph from the learning chapter. Please note that the links below take you to posts I’ve written about specific parts of the brain. The two prefrontal cortex links will take you to two different posts.

A lot of the research I’ve mentioned in this chapter revolves around exercise’s effect on the hippocampus, because its role in forming memories makes it vital to learning. But the hippocampus isn’t off by itself somewhere, stamping out new circuits on its own accord. The learning process calls on a lot of areas, under the direction of the prefrontal cortex. The brain has to be aware of the incoming stimulus, hold it in working memory, give it emotional weight, associate it with past experience, and relate all this back to the hippocampus. The prefrontal cortex analyses the information, sequences it, and ties everything together. It works with the cerebellum and the basal ganglia, which keep these functions on track by maintaining rhythm for the back-and-forth of information. Improving plasticity in the hippocampus strengthens a crucial link in the chain, but learning creates bushier, healthier, better connected neurons throughout the brain. The more we build these networks and enrich our stores of memory and experience, the easier it is to learn, because what we already know serves as a foundation for forming increasingly complex thoughts.

Exercise Lights A Spark

I recently finished reading John Ratey’s SPARK The Revolutionary New Science of Exercise and the Brain. 

I suppose one mark of a well-written book is how powerful an impression it makes on the reader. The premise behind SPARK was not a surprise – I’ve heard John Ratey make his case at last Fall’s Learning & the Brain conference, and my years of dedicated swimming have already proved the points first hand. Rather, it was Ratey’s earnest discussion of how exercise boosts the brain, and his explanation of the biology, coupled with chapters covering everything from learning to stress to depression to attention deficit to hormones to aging, all the time with his practically begging us to take notice and don’t just sit there but DO SOMETHING about it, which got me all fired up in a good way!

Ratey begins by sharing the story of Naperville Central High School in Chicago, Illinois, which implemented a phys ed program based upon PE4Life that completely changed the dynamics of school gym class. Instead of a focus on sports teams, the focus became Getting & Staying Fit. A major component of the program was the use of heart rate monitors so students could exercise at the intensity level best for their individual health. This program wasn’t about competition or comparison, but simply about what was best for each student.

Two other important pieces of the program afforded students the opportunity for choice and control over their gym classes. There are close to twenty different activities from which students can choose as they build their fitness plan to cover four years of high school. Some of the activities have always been part of phys ed programs, such as basketball and volleyball, but a climbing wall and kayaking surely weren’t options when I went to high school. The activity that makes me smile widest is their use of DDR, which stands for Dance Dance Revolution.

When our oldest son was in high school, he and two friends had jobs at New Roc City demonstrating and teaching how to use the DDR machines. Of his four years in high school, he was the most fit during the time he worked at New Roc. With his friends, they tried to convince the director of their school’s athletic center to include DDR as one of the activities, but to no avail. They participated in contests, taking bus and trains (and cajoling parents to drive them) to areas in Queens, NY, that were known to have the best DDR machines, and shared video of their routines with other DDR aficionados.

Phil Lawler, the Director of PE4life Instruction and Outreach, testified before the United States House Subcommittee on Healthy Families and Community in May, 2007. You can read his testimony here. I am going to share this pdf with faculty at my school – not because I question our phys ed program, but because I think the adults in my school community could benefit from understanding the brain~body connection, and perhaps apply this to their own lives.

A New Year and Brain Fitness

As a kid I enjoyed making New Year’s resolutions, even though there was never any intent to carry them out. Rather, they simply provided the same sense of satisfaction as cleaning out my loose leaf binder for school; I knew everything would get messy again but it was nice to have a fresh start! I’m not making any resolutions, or suggesting you should, about brain fitness programs, but mentioning them at the start of a new year tickles that same sense of satisfaction.

Coincidentally, as I sat down to write this post, I checked Neurons Firing to see what I wrote around this time last year. Turns out on January 20th I posted about Michael Merzenich. Big deal, you may say. Well, among other occupations, Merzenich has a company called PositScience that focuses on brain fitness. Hmm, January and brain fitness – there’s that tickle again! 

There have been a number of prominent neuroscientists who have talked about the benefits of keeping one’s brain fit by using a combination of physical exercise, and stimulating, novel mental challenges. The latter comes under the arch of brain fitness, which has emerged as a market onto itself, complete with digital programs designed to challenge the brain, one level at a time.

SharpBrains, where I guest blog, specializes in assessing the brain fitness market, and makes its research available via several formats. In March 2008 they published The State of the Brain Fitness Software Market, a summary of which can be accessed  here. SharpBrains also has a useful post containing a 10 item checklist to help select brain fitness programs. 

Also in 2008, Dan Rather filed a report called Mind Science. The report is broken up into six parts, all of which are available on YouTube. Below is part three, which focuses on brain fitness, in particular PositScience. Approximately 8 minutes into the video, Rather and Eric Kandel provide a fascinating look into memory.

I have no experience with any of the brain fitness programs, so cannot speak to their effectiveness or ease of use. However, I have written extensively about the benefits of providing novel challenges to the brain as a way of strengthening memory and creativity. I am convinced there are benefits for older folks in getting baseline cognitive testing, particularly if there are concerns about memory, general functioning or if there is a history of age-related cognitive decline in the family.

Below are links to brain fitness programs and related articles. If you have experience in this field, please feel free to turn this post into a conversation!

This first set of links comes either from searches I did or readers of Neurons Firing.

• Eaton Brain Improvement
• PositScience 
• Senior Journal – Brain Fitness Program Clinical Trial Attracts 500 Senior Citizens
• New Brain Fitness Program In High Demand – Erickson Knows Fitness Isn’t Just About The Body
• Allstate Launches Brain Fitness Program to Improve Older Driver Safety
• Mind Sparke – Brain Fitness Pro
• Brain Fitness Program and Neuroplasticity at PBS
• Lumosity

This set of links are to programs mentioned in the earlier referenced SharpBrains report.

• Advanced Brain Technologies
• Applied Cognitive Engineering’s Basketball IntelliGym (brain training for basketball players!)
• The Brain Resource Company
• BrainTrain – designed to help folks with ADD/ADHD and related brain issues
• CNS Vital Signs – “measure, monitor and manage” neurocognitive function
• Cogmed – designed to improve memory, focus and concentration
• CogniFit – “enhance cognitive abilities thus improving the quality of life”
• Cognitive Drug Research – cognitive testing
• CogState – cognitive testing for clinical trials
• Dakim Brain Fitness  – “The fight against dementia starts here” – A wonderfully organized and implemented site, complete with video of the founder explaining the site in an easy to understand, welcoming manner
• Lexia Learning – specializes in reading from pre-K through adults
• MyBrainTrainer – “virtual mental gymnasium”
• Nintendo Brain Age
• Scientific Brain Training
• Scientific Learning – for ESL and Special Ed
• Teach Town – “for children with autism spectrum disorders”

Nelson’s Memory Nuggets

When I think about the body-brain connection, the spiritual Dem Bones comes to mind. Perhaps you are familiar with the lyrics for this tune about the connection of one bone to the next, starting with the toes and going all the way up to the head and then back down again. It ain’t just the bones that are connected; our entire internal system is connected, and that includes the brain!

According to Aaron Nelson, there are a number of reasons, in addition to those related to normal aging, that our memories become less optimal as we age.

• poor sleeping due to habits or physical issues
• hereditary factors 
• hormones that act up
• age-related illnesses
• neurological illnesses
• side-effects of cancer treatment
• accidents to the head
• exposure to excessive stress
• taking certain medications or drugs
• eating a nutritionally poor diet
• excessive alcohol intake
• inadequate exercise
• insufficient intellectual stimulation
• smoking

While some of these factors are beyond our control, many of them are manageable. For those that are manageable, making changes will likely improve both cognitive functioning as well as physical functioning. Nelson’s prescriptions sound like common sense, and most are suggestions that have been touted in the news at one point or another as facilitating improved health in a part of the body. Many of us are general practitioners of our own health, so it may behoove us to remember that our internal systems are interconnected, and delight that improved memory is now added to the list of benefits that can accrue from taking care of ourselves. 

Here are Nelson’s Memory Nuggets:

Obtain regular exercise 

• lowers the risk of dementia and Alzheimer’s
• increases brain plasticity
• helps manage weight
• helps manage stress

Put out the cigarettes

• give your lungs and blood vessels a reprieve
• unfog your memory and your cognitive functioning

Take vitamins

• antioxidants fight against free radicals
• antioxidants may protect against memory loss

Involve yourself with others

• social stimulation improves mood
• interacting with others provides cognitive stimulation

Maintain healthful nutrition

• read Walter Willett’s Eat, Drink, and Be Healthy
• Frontline interview about nutrition with Walter Willett
• check out the foundation of Willet’s healthy eating pyramid

Aim for a good night’s sleep

• six hours is minimum needed
• helps cement new learning

Learn something new

• engaging in novel challenges promotes memory and cognition
• cognitive reserve applies to lifelong learning

Moderate alcohol intake

• one to two drinks of red wine might help fend off dementia
• excessive alcohol promotes memory loss

Engage in life

• learn something new
• engage in social interaction
• stimulate your mind
• feel worthwhile

Manage stress

• high levels of stress make it difficult to attend to new information, thus impacting memory

Organize your thinking, organize your life

• organization aids memory

Routinely take precautions to protect your brain

• “Head trauma is a major cause of memory impairment in young people and a risk factor for later development of dementia.” (This direct from Nelson, who serves as the neuropsychology consultant to the Boston Bruins hockey team.)
• wear helmets, mouth guards and seat belts

Yes you can! Maintain a positive attitude

• All of the above are within your control to manage, and are worth managing for both your physical and mental health.

Memory 101 (Aaron Nelson)

When we talk about memory, we mean not only all that we remember but also our capacity for remembering.

So writes Aaron Nelson at the beginning of chapter 1 in his book The Harvard Medical School Guide to Achieving Optimal Memory.

Think about what it is you tend to remember. Most likely, if your memory is fairly typical, you tend to remember items and events that are important to you. The information is important because you need the facts or because there is some emotional pull or because you make use of certain processes to accomplish certain tasks. Did you know that each time you reference a memory, it can get altered, because your memories are not static.

Our memory apparatus consists of two components – short-term and long-term. Their names simply designate the duration of the memory. 

SHORT-TERM
Short-term memory can hold a string of 5 to 7 items, is what you make use of when you only need to briefly reference something, and dissipates quickly, especially if you are interrupted in the process of using it.

WORKING
You’ve probably heard of working memory, either as being the same as, or a form of, short-term memory. Nelson explains working memory as a more sophisticated part of short-term memory, in that it is used to hold onto information necessary for a “specific purpose” and, once used, as with the rest of short-term memory, it can be discarded.

LONG-TERM
Long-term memory, as its name suggests, is of a much longer duration. In fact, it stretches way back to your childhood, and is like a bottomless well in what it can hold, though not everything in long-term memory remains there forever. The kinds of memories you hold onto for the long-term include Declarative (also called Explicit) and Procedural.

DECLARATIVE (EXPLICIT) –> EPISODIC & SEMANTIC
Declarative memory is more susceptible to aging and illness because memories of this type are stored in the hippocampus, which gets a bum deal as it ages, and is particularly hard hit by diseases such as Alzheimer’s. 

Your episodic memories “are linked to events that occurred at specific times and in specific places” (like episodes in a television series that air on certain dates), whereas your semantic memories (like words and their meanings) are those items that you just “know”, but would be hard pressed to detail when or where you learned them. These memories consist of facts and meanings.

PROCEDURAL
This last type of memory consists of “the skills and routines that you draw on automatically to perform actions” as part of functioning as a person. Nelson writes that “Even people with Alzheimer’s disease can perform many routine tasks until the advanced stage of the illness. Scientists believe that procedural memory is robust because it is stored widely throughout the brain [including the frontal lobes, cerebellum, and basal ganglia]  and because it is not dependent upon the hippocampus, one of the memory structures within the brain that is particularly vulnerable to the effects of normal aging.”

Did you know that what is good for your body is good for your brain? Taking care of your body is taking care of your brain. (Yes, it bears repeating!) In my next post, some practical advice from Dr Nelson.

Further resources about Memory:

• KidsHealth – Memory matters
• Neuroscience For Kids – Memory Experiments
• Neuroscience For Kids – Alzheimer’s Disease
• Exploratorium Memory exhibition

The Aging Brain (Aaron Nelson)

Aaron Nelson began his Learning & the Brain session by telling a tale on himself regarding memory. If you’ve ever left home on a car trip and wondered if you turned off the coffee pot or the stove or some other gadget, Nelson’s tale of forgetting his child’s blanket and returning home only to discover that he had left the keys to their other car in that car, which was parked in the driveway and running, will resonate! He went on to describe the components of memory, which consist of “multiple memory systems” as explained by Larry Squire and his memory schema. Scroll to the third page and notice that  the diagram, which references long term memory, shows memory as residing in multiple areas of the brain.

The bulk of Nelson’s talk focused on how the brain and memory change with age. Did you know that “memory starts to decline between 25 and 30 years of age in normal situations.” He explained a bit about what scientists think happens in the brain in terms of aging and memory, further explained the concept of “cognitive reserve”, and then discussed ways to optimize memory. No doubt one reason his talk was well attended is that every last attendee had an aging brain, and a number most likely also have parents who are well ahead in the aging arena!

I took a lot of notes and was persuaded by the practical nature of Aaron’s talk to then purchase his book, The Harvard Medical School Guide to Achieving Optimal Memory.

Of particular interest was Aaron’s description of Yakov Stern and his study of cognitive reserve. SharpBrains has an informative interview with Dr Stern entitled Build Your Cognitive Reserve. I referenced cognitive reserve, or the brain-reserve hypothesis in my prior post on Ken Kosik’s talk.

As with many of the books I read, an entry or two about Aaron Nelson’s book will eventually wind up posted here. Meanwhile, I leave you with this teaser from his book:

Obtain regular exercise
Put out the cigarettes
Take vitamins
Involve yourself with others
Maintain healthful nutrition
Aim for a good night’s sleep
Learn something new
Moderate alcohol intake
Engage in life!
Manage stress
Organize your thinking, organize your life
Routinely take precautions to protect your brain
Yes you can! Maintain a positive attitude

(and a promise to myself to stop buying books until I’ve read all the ones waiting for me!)

Gregory Petsko’s TED Talk

Jack, of clarityworx, shared this link to Gregory Petsko’s TED Talk: The coming neurological epidemic. This is the perfect time to point you in Petsko’s direction, inserted between my post on Ken Kosik’s talk about Alzheimer’s and my upcoming post covering Aaron Nelson’s talk on memory. 

It’s also the perfect time to ask any of you who are WordPress folks for some advice. I would love to be able to use the embed commands from TED Talks – has anyone figured out if it’s possible to make them work? Currently I have to use youtube, which is fine, except for occasions like this when the TED Talk is not yet posted to youtube.

Thanks for any insight anyone might provide!

December 6 – Petsko’s TED Talk is now on youtube, the code for which embeds nicely in wordpress, so here it is:

The Adult Brain & Memory (Ken Kosik)

The theme of November’s Learning & the Brain conference was Using Emotions Research to Enhance Learning. As with last April, when I believe it was first introduced, there was an Adult Learning strand. Saturday morning I had the pleasure of presiding over the Adult Brains & Memory session, which featured two talks:

• The Adult Brain & Memory: How Learning Protects Against Alzheimer’s, by Ken Kosik
• The Aging Brain: Optimizing and Protecting Memory, by Aaron Nelson

My Dad has Alzheimer’s, and hearing about what is going on within his brain is something that I can listen to over and over again, hence my second time as an audience member for a talk by Ken Kosik. In the cozy environment of MIT’s Brain & Cognitive Sciences auditorium, Kosik took us from the statistics on aging through the neurofibrillary tangles and amyloid plaques of Alzheimer’s to MCI (mild cognitive impairment) to studies and practicalities of hedging against Alzheimer’s, to adult brain plasticity, to wondering just where memories go. In my May 23rd post of this year you can read more about what Ken shares regarding Alzheimer’s.

In this recent talk, I did pick up some new information, and was reminded of some old. Being a teacher, and having very definite opinions about professional development formats, I especially enjoyed Ken’s three-point proof that Education protects against Alzheimer’s.

• Brain-reserve hypothesis – If you start out strong, you’ll decline less.
• Brain-battering hypothesis – Better-educated people take better care of themselves, and therefore may be better protected. Lesser educated people have more stroke, myocardial infection, diabetes, depression and earlier mortality.
• Diagnostic bias – Highly schooled patients score higher on dementia screening and tests of cognitive ability.

Kosik also pointed out some very salient features to keep in mind. Perhaps the most protective factor against Alzheimer’s is having friends, social networks, and being connected.

While all rules do not apply to everyone – each of us is, after all, an individual – the rules are based on statistics, and we can use these generalizations to guide us in our decision making in terms of preventive care and general health care.

Dealing with the aging brain and how it can impact our lives is at the very heart of what Ken Kosik studies. To that end, in addition to his long list of impressive credentials, he is the Executive Director of the Center for Cognitive Fitness and Innovative Therapies at Santa Barbara, California, part of whose mission is:

…we believe that every person has the ability to age gracefully and live a full active life even with a diagnosis of Alzheimer’s. The key is integrating all the tools you need to thrive under one roof. 

(Next post: Aaron Nelson’s talk)

Alzheimer’s and my Dad

Last time I wrote about Ken Kosik’s talk The Adult Brain and Memory: How Learning Protects Against Alzheimer’s, given at the Learning & the Brain conference this past April. This morning my Mom sent me a link to a New York Times article about the University of Colorado, politics, and political chairs. While at the NYT site I started to read today’s paper, which brought me to Zen and the Art of Coping With Alzheimer’s.

I began Neuron’s Firing a little over a year ago, in April of 2007. One of my early posts, Brain Stats, covered not only statistics about the size and contents of our brains, but also noted one reason why the brain was of such interest to me. My Dad has Alzheimer’s. He is 82 and a half years of age and lives in a nursing home fifteen minutes from my home. His sister, who was seven years older than he, was operated on for a brain tumor in her 70s and somewhere in her 70s or 80s developed Alzheimer’s. She died of complications, perhaps from a stroke, in her 80s. And there is some question as to whether their mother, who lived into her early 90s, had Alzheimer’s, as well, though there isn’t anyone around who is able to clarify this for certain.

It is particularly interesting to watch the two videos on the Zen and the Art of Coping With Alzheimer’s page: Alzheimer’s: Quest for Understanding, and Alzheimer’s: The Rarest Gene. Both videos tell personal stories but also include research, interviews with researchers, and images that help give a picture of what is happening to Alzheimer inflicted brains.

There is no easy way to watch my Dad degenerate, but I discovered a way to keep him close; I started a blog on his behalf. The entries are packed with pictures and even some short video clips, and I write about what we do during my visits. Somehow, this makes me feel like he still has his voice, and meanwhile I am building a memory bank for him/of him, that everyone in the family can read. And on those visits that turn out to be tough, knowing I’ll be writing about it later has, so far, made those visits a little bit easier.