Neurofeedback and the Aging Brain
The near-win of Tom Watson at the British Open Golf Tournament at the age of 59 gives us the impetus to address the issue of healthy aging. Everywhere the elderly are sticking around, in careers, in positions of power, and even in sports where youthful eyeballs, strength, and stamina confer an advantage. The present concern about the looming health care crisis, however, focuses us ever on the other part of the spectrum, the gradually deteriorating health status of the elderly. Our present system of health care seems to do well at keeping people alive, but often with very little quality of life. With an ever growing contingent of the elderly, the costs keep creeping up, but the return on our societal investment keeps diminishing. The movement toward healthy aging not only promises to increase the return on that investment, but it also gives hope of making inroads into the cost of health maintenance itself. Read on.
In our current orientation in medicine, the tendency is to regard certain symptoms as a natural part of aging and then to adopt a policy of “watchful waiting,” particularly when we don’t have a ready remedy in any event. The same passivity, however, afflicts the research community. As the cartoon says, “Not only is there no cure, but there isn’t even a race for a cure.” This might be defensible if it weren’t for the fact that ignoring some issues just sets the table for worse to come. Further, some emerging health problems are quite optional, as we shall see.
A second major tendency of our current medical model is to strive for specificity in diagnosis. This tends to reify the condition as distinct and separable, and calls for a specifically targeted remedy if one is available. This focus on the particular tends to obscure the larger picture that may explain multiple phenomena. Examples of such false specificity include insomnia, constipation, incontinence, restless leg syndrome, snoring, anger and irritability, agitation, forgetfulness, tinnitus, and various pain syndromes.
With regard to the larger picture, I was startled to read an article on Silent Diseases by Eric Braverman, MD, in the Life Extension Foundation Magazine (August, 2009 issue). The basic message was that disease processes can be recognized in their early, silent stages, where prevention and counter-measures ought to begin. In reducing his approach to beating the Silent Diseases to four key principles, two of the four relate to brain function. “Deliver health care HEAD FIRST,” is the first of the key principles. “Take brain dominoes into account,” is the fourth.
With respect to the first of these, the reader is enjoined to “Interpret all medical conditions with respect to the brain and nervous system for a total brain health and anti-aging program.” With respect to the fourth: “The body is known to react to many illnesses with a domino effect, in which one small change can affect the workings of the entire body. In most instances, I see that first domino falling as a symptom of brain imbalance.”
These prescriptions came at the conclusion of an article that was chock-full of specific measures against common medical hazards and conditions. None of these, however, were directed specifically toward issues of brain-based dysfunction. Perhaps the reference to brain imbalance was intended to convey the reader to the tender mercies of modern biological psychiatry. However, even in our most charitable frame of mind it would be difficult to see modern psychiatry as a positive force in anti-aging medicine. Braverman recognizes the problem; yet the remedy escapes him.
So let us hasten to help out a medical industry that is still groping in the dark with respect to maintenance of functional competences in the brain. In our emerging perspective, irritability, anger, forgetfulness, agitation, insomnia and snoring are some of the first signs that point to a problem of brain disregulation. The brain is not managing as well as before in mood and emotional regulation, memory access, executive function, and sleep organization. The quality of sleep can be considered the first of Braverman’s dominoes. Once the quality of sleep declines, the rest of brain function follows in a kind of reverse hierarchy.
Memory is one of the best measures of brain functional integrity. The decline of memory function is one of the first signs of brain aging of which the person may become aware. The quality of sleep is also a key issue for the maintenance of immune system functioning. If good sleep architecture could be maintained, the decline of brain function in other areas could be forestalled. As it happens, the medical management of sleep disorders is a disaster area, to which the recent deaths of Michael Jackson and of Heath Ledger can attest.
With neurofeedback, on the other hand, we can in nearly all cases, essentially without exception, improve the quality of sleep in those with sleep onset or sleep maintenance difficulties. We are not dealing here with a simple matter of a “brain (chemical) imbalance.” Rather, we are confronted with an exceedingly complex orchestration of sequential sleep stages that the brain must manage on its own. All we are really in a position to do is to train the brain toward functional competence generally, which in turn leads to better sleep management.
If sleep disregulation is not addressed, problems tend to get worse and yet other problems tend to show up. A simple case of snoring may end up a more complex case of sleep apnea. We may also see restless leg syndrome and nocturnal myoclonus, both of which respond readily to neurofeedback.
If sleep disregulation is addressed, we can expect better memory function, better executive function, and improved emotional tone and stability. The techniques we use in neurofeedback impinge on these functions directly as well, so these improvements don’t all follow just from improved sleep. The issue of sleep regulation is represented here as paradigmatic for a more general insight, namely that improved brain function lies at the heart of initiating a virtuous circle with respect to both functional competences and health maintenance generally.
Another such over-arching paradigm is stress management. It is generally understood in the medical culture that some 85% of medical conditions are either mediated by or exacerbated by stress. And it is a matter of simple observation that the elderly have a progressively lower stress tolerance as they age. But what does that really mean in bio-medical terms? An adverse stress response means simply that the brain enters a state of disregulation upon exposure to precipitating stress. That is to say, the state of functioning that was adequate at lower stress levels cannot be maintained as stress levels are raised. The resulting functional deterioration is a nonlinear function of stress. There is a threshold, and beyond that the brain actually declines in its ability to manage the situation. Like a leaking boat taking on water, eventually it just sinks.
With this picture in mind, it is obviously of great import to maximize stress tolerance at every stage of life, to postpone those sinking moments. Again, stress management within the medical arena is a disaster area. It remains terra incognita until such time as it can be labeled in standard categories such as anxiety and depression. But the whole field of biofeedback has emerged over the last four decades to develop superb competences in this arena. Once the importance of stress tolerance is fully appreciated, the value of biofeedback as a counter-measure will have to be acknowledged. And even when the diagnostic threshold is reached for Anxiety Disorder or Depression, the remedy of choice should be neurofeedback. The brain can be readily trained out of these conditions, either with or without modest pharmaceutical supplementation.
A third area of concern is that of pain management. As people age, pain is increasingly likely to become an ever-present companion, and eventually one can even end up with full-blown chronic pain. Few things drain the joie de vivre out of a person as effectively as chronic pain. There is a strong association here with depression, but it is really more useful to regard both persistent pain and depression as manifestations of brain disregulation. Even if the pain has an obvious physical cause, brain disregulation can contribute to making it worse, and to making it persist. Pain is not absolute. It is one of those nonlinear processes that depends on many factors such as emotional ambient, and brain disregulation can exacerbate our experience of pain.
Then we have the common medical problems of the elderly that don’t have an obvious connection to brain function, such as constipation and incontinence. It is our clinical experience that neurofeedback can resolve both conditions, often quite readily. This can only be interpreted to mean that the quality of brain function has implications for the regulation of bodily functions generally, not only those that we associate with the nervous system directly. So brain function looks like it’s Braverman’s first domino for a variety of “medical” conditions.
Finally, we come to the principal killer diseases among the elderly, the real focus of medicine, namely cancer, heart disease, stroke, and diabetes. Once these major disease processes are no longer silent, one should certainly wish for a competent brain to accompany one’s journey through the medical procedures. Even here, the brain is directly involved in the issues. Neurofeedback can be of significant help in the case of Type II diabetes, even to the point of reducing any insulin requirement. The brain is intimately involved in the regulation of heart function. Stroke recovery can be significantly aided with neurofeedback. And we can alter immune system status in a favorable direction with regard to cancer.
Alzheimer’s and non-Alzheimer’s dementia are not killers per se, but they do promote an earlier death among the caregivers. Here neurofeedback can forestall the worsening of symptoms, probably for some years. The same can be said for Parkinson’s. With neurofeedback, the benefits may be comparable to those of Deep Brain Stimulation, without the costs and the risks.
So, what’s the action item? There are lots of ways to aid brain function, but on a matter so central to one’s well-being, people would be well advised to start out on this journey with a professional. Neurofeedback training of brain function is the most highly developed technique in this area, and it is our principal field of interest. We believe it’s a good idea to get started with a neurofeedback practitioner. They don’t necessarily understand all of the issues raised above. It’s just that they are a step ahead of everyone else. One can then continue with occasional “brain-brightening” sessions, as needed. And neurofeedback can be complemented with home use techniques such as auditory stimulation training, cognitive skills training (e.g., Brain Builder), audio-visual brain stimulation, and low-level electromagnetic stimulation (Enermed). Even engagement with classical music helps to keep the brain challenged and engaged.
The benefit that can be derived from these methods proves that the issue is not chemical imbalance in first instance, as the pharmaceutical industry would have it, but rather the quality of brain function in all of its particulars. These all relate to the brain’s essential role as a communication system, which in turn depends on exquisite timing. The techniques mentioned have one thing in common: they represent a time-dependent challenge to the brain. This is the key to better brain function, and it is something that neither neurology nor psychiatry has thus far understood.
With this as background, we confront then the psychological challenges faced by the elderly—the loss of loved ones and the progressive loss of one’s own competences. It turns out that one’s sense of loneliness is not at all a function of the size of one’s social networks. Loneliness is yet another indicator of the quality of brain function. Our interior realm mirrors the outside world. If we have rich social ties, we also have a rich internal conversation in our brains. That internal conversation can remain rich even when the physical ties are stretched or even broken, provided that memory access remains intact. All this is a matter of functional connectivity of our brain networks, for which chemical balance is a necessary but not sufficient condition. Neurofeedback can promote that functional connectivity—indeed that is the primary mechanism of efficacy of neurofeedback. Through neurofeedback, then, we can contribute significantly to quality of life among the elderly, and we can keep them productively engaged. Neurofeedback has come along just in time. By 2050, some 30% of people in the developed countries will be over 60 years of age. The management of dysfunction in such a population will be a priority, and it is doubtful that idleness on the part of such a large cohort will be tolerated in the evolving social contract.
The ultimate silent disease, in Eric Braverman’s idiom, is the non-optimal functioning of our cerebral networks. Once that is recognized, maintaining our brain function will become a principal and indispensable pathway to health maintenance in the elderly as well as to enhanced functionality along the way. As long as this is not recognized, however, our remedies are likely to be counter-productive. By addressing symptoms such as insomnia, pain, agitation, or constipation directly, the underlying cause of brain disregulation remains unaddressed, and is likely to loom progressively larger as the years pass. A vicious circle is set in train in which the person becomes ever more difficult to manage, ever more unpleasant to deal with, and eventually succumbs to one of the classic disease processes. All of this is quite unnecessary.
In the current health care debate, matters are hung up on the issue of “bending the cost curve” downward. This is not easily legislated because no stake holder wants to give anything up. Everyone, however, is ultimately forced to yield to technological progress. Innovation will be the means by which the cost curve is bent, and nothing is quite as promising as the frontier of enhancement of mental functioning that beckons with neurofeedback.