How to Boost Your Brain With Custom Exercise

Ryan Glatt

Yes, it’s great to be here. Dr. Sandison, thank you so much for having me.

Heather Sandison, ND

You have many more accolades, but I know our listeners just want to dive into the nitty-gritty of this and also the actionable steps. Can we first start with how important exercise is for brain health, whether we’re in prevention mode or attempting reversal?

Ryan Glatt

I think when we’re talking about things like dual-tasking and brain health, there are a lot of interesting things we can fixate on. But I always start by talking about what is good for the brain, and you talk a lot about those things. Of course, exercise is one of those things that everybody agrees is good for the brain, and it’s very difficult to pick favorites. I can barely pick out a favorite color or a favorite restaurant, but certainly, in terms of evidence, weight, and how much evidence there is, there seems to be quite a bit for exercise and brain health. Of course, it depends. There’s always more research that’s needed. However, the research is quite convincing in understanding whether or not exercise is good for our brains. It certainly is. 

There’s a lot of different reasons. It could be good for our brains. Most importantly, I think a healthy diet can be good for our brain health. Different aspects of exercise may yield different benefits, perhaps unique benefits. I think that’s where it gets exciting, and so many people have a different relationship with exercise. I know growing up, it’s always been about weight loss, looking good, and your body composition. But as soon as I came to understand the mental health and brain health benefits of exercise, it was almost a different type of motivation. When I speak with individuals, especially those who have the goal of preventing cognitive decline or already have some cognitive impairment and want to further reduce that decline, exercise becomes more of an ally than a chore that you have to check off.

Heather Sandison, ND

You mentioned that we all agree that exercise is good for us. But when you break down some of the big buckets, why is it good for us? What are the mechanisms?

Ryan Glatt

Yes, I will categorize the mechanisms at three different levels. The first level is the micro level. This is all the cool stuff that we hear about but can’t see or feel in everyday adult human brain life. Some things are expressed at the micro level, such as molecules, hormones, and proteins, that may have been discovered through animal studies or other research. This includes things like brain-derived neurotrophic factor, or BNF, which we hear a lot about. It could be IGF-1, or intellect growth factor-1, or nerve growth factor. It could be certain types of precursors to those growth factors. Growth factors are anything that tells the brain to grow, survive, and do good things so that we can live a long, healthy life and have great brain longevity.

That’s all at the micro level. In addition, things change at specific neuronal levels. Neurons are brain cells for those who don’t know. when we have any assumed change to a neuron, a neural network, or connections between neurons. A lot of people refer to it as neuroplasticity. That would also be at the micro level. However, you never go to the doctor and say, Hey, how is this one neuron, doc? Or, Hey, where are my levels of BNF now? Of course, you can do that, but we don’t have that. This equals that approach at the micro level, but it’s all the cool things that we assume are happening that we hear are happening. The micro level is good to understand because, when we want to understand how different types of exercise or different aspects of exercise affect the brain, the micro level might have some explanations. We can come back to that. 

Then there’s the macro level. If you were to go to a neurologist and get a brain scan, you could look at the brain at a structural level or a functional level. At the structural level, when we look at an MRI, we see how big the brain is in certain regions and certain aspects of volume. Then we could also do a quantitative EEG to look at the function of the brain. Exercise can help with both. It can help with brain function and brain structure, depending on how long the study was, the population, and what the intervention was. But generally speaking, it can preserve brain structure, even increase brain volume in certain regions over certain periods, and improve the efficiency of brain activity. 

Then we look at the behavioral level, and the behavioral level is the important one because that’s the one we see and feel every day. This is not only an improvement in mood but also an improvement in cognition, attention, memory processing, speed, and executive functioning. All of these things can be measured in different ways. But you don’t; it’s advised that you get testing, whether neurocognitive testing or neuropsychological testing. But for those that don’t, if they undergo a 12-week exercise program and feel sharper, hey, that’s valid. That’s a very important thing. Or if I go to the gym just after one session, I have better mental health or better mood states, or I feel a little sharper. That’s certainly valuable. That’s at the behavioral level. In review, it’s the micro, macro, and behavioral levels. It’s easy when you categorize. I categorize it that way. But if you take all the mechanisms out of the file cabinet and throw them on the ground, a lot is going on here, and certainly we could dove more into it. But I think it’s important to be more pragmatic.

Heather Sandison, ND

I had the pleasure of coming and visiting you at the Pacific Neuroscience Institute not that long ago, and you gave us a tour of the brain gym. Would you describe what it is? I want everybody to know what’s there. At this ideal level, if you have access, and certainly if you’re in Santa Monica or West Los Angeles, reach out to the guys at the Pacific Neuroscience Institute. They’re doing incredible things. But I want to take us through an audio tour of what’s going on there. Then also, if you can relate it to what people could maybe be doing at home if they don’t have your fancy machines.

Ryan Glatt

I think before we do that I could just identify the types of exercise. The brain gym stuff and the dual tasks and stuff within those categories, and then coming back around to how we can apply it to what we do. There are different categories of exercise. There’s aerobic exercise, which is anything that gets your heart rate up. There is resistance training, which usually includes bodyweight exercise but mostly refers to weightlifting or strength training of some kind with external loads of resistance from weights or bands. Then there’s what’s called neuromotor training. Neuromotor training is something that people don’t talk as much about, and it’s a very diverse category. It can include sports; it can include dance; it can include martial arts; it can include mind, body, exercise, yoga, tai chi, qigong, and places in between. It can also include anything that’s an open skill. 

An open skill is anything that’s more unpredictable and that you have to constantly adapt to, a sport like ping pong, a dance class, or something else, versus a closed skill, which is what’s happening and when. If I sit down at a weight machine there, there’s not going to be any surprises. so both are good. We both need close skills and open skills, but open skills are more cognitively demanding. Because of that, there’s some research showing that there might be unique cognitive benefits from open-skill exercise when compared to close-skill exercise. That’s not villainizing the close skill. We still need that, but hey, it seems to make sense that when we engage our brains while we move, there seems to be some additional benefit there. That makes sense. 

Now some people want to address or isolate those cognitive challenges specifically and deliver them while people are moving. There’s this practice; there are two things called dual tasking and extra gaming, and I’ll define both of them, but they both are more artificial ways of giving someone a set of cognitive stimuli while they’re exercising, whereas sports, dance, and martial arts are more naturalistic in how they do that. It’s the supplements of cognitive and physical training if that makes sense. But there’s a lot of research to show that extra gaming and dual tasking can improve cognition, balance, and walking function in a whole host of populations, even in individuals with neurological or neurodegenerative conditions. Individuals with a specific cognitive goal, such as those in the populations I just stated, might want to engage in exercises that are specifically more cognitively demanding.

Aside from the heavy backstory,  dual tasking is defined as doing something mental and physical simultaneously, or at least something that’s called cognitive-motor dual tasking. That’s what it’s responsible for. Walking while talking is the most naturalistic dual task. I can give an example of a cognitive-motor task. A less naturalistic one is counting backward while walking. I say it’s less naturalistic because no one just goes and does that. No one’s. I’m going to go out for a walk and count backward while I do that. That’s not exactly anyone’s idea of a good time, but those are cognitive-motor dual tasks. Then there’s X Games, and as a kid, I had a traumatic brain injury and was pretty overweight, but I was addicted to video games, and there was a thing called the Dance Dance Revolution. 

For those that don’t know about it, and for those that do, it’s, Yes, I know what that is. It’s a pad or a mat with four arrows, one pointing up, one pointing down, one pointing left, and one pointing right. You’re playing a dance video game. That’s how I lost weight as a kid. Then that led me to get into the gym. But it also helped me cognitively. I was terrible in school, and it allowed me to improve my social behavior, my academic performance, my cognition, and my processing speed. Everyone has probably also heard of the Nintendo Wii or We Sports. These are examples of General Xer games. While they seem fun, silly, and pointless, there’s a lot of research to show that these can help with physical function, motor function, and cognitive function because they’re challenging the mind while also challenging the body. 

Heather Sandison, ND

What about balance? There’s probably a whole host of other things, but balance comes out.

Ryan Glatt

Yes. That’s part of the physical function. When we say physical functioning or motor function, we can mean anything from grip strength to balance improvements. Balance is one of the main things between balance and cognition, which are linked inextricably. What’s cool about these extra games is that they’ve come a long way in terms of being more specific. There are extra games for Parkinson’s, there are extra games for persons with dementia, and there are extra games for older adults with balance deficits. These are called specific or clinical extra games, and they have elements of dual-tasking embedded with them or within them. 

The Fit Brain Program here at the Pacific Neuroscience Institute is a whole collection of these different extra games and dual-tasking approaches. We call it a Brain Gym. Other people have taken a similar approach to cardiovascular rehab, where they are putting forth more effort without knowing it because they’re focused on the game. People have called it a Clinical Arcade, which I’m perfectly fine with because I loved Chuckie E. Cheese as a kid. I love Dave and Buster’s; I love arcades. What if you’re exercising? What if your rehabilitation could feel like an arcade experience? That’s not infantilizing, but it’s just fun. You have this sense of autonomy and want to beat your score and improve upon yourself. I think gamification is certainly something that can harness that.

Heather Sandison, ND

Yes, we’ve talked about that a lot. It’s much easier to stick to something if it’s fun. But also, some data shows that we get more cognitive benefits if we’re having a good time than if it’s less stressful. Are there strategies that you’ve used outside of what you’ve already discussed to make it more fun?

Ryan Glatt

I think sometimes there’s a lot of fun to be had in this world of exercise, and a lot of people avoid it because they think it’s the opposite. For people to do this at home, you don’t need to get a big brain-training set of lights, walls, or whatever. Of course, there’s something about virtual reality that’s becoming much more affordable. I play a lot of virtual reality games. I play ping pong at home against my brother on the East Coast all the time. There’s a lot of brain-body games available in virtual reality. But for individuals who want to do this at home, it’s simply asking the question, What do you enjoy? What have you enjoyed in the past but haven’t done in a while, or what have you tried that you might enjoy?

I think the latter one is a question to ask because there are so many things that people haven’t done. If you think of every sport, every dance, every martial art that you can think of, and every extra game you can think of, there’s an overwhelming amount of options there. Just go in based on the question: What have you enjoyed? is only as extensive as that person’s experience. I haven’t met a person who’s done more than five sports. There are a lot of things to sample. Even if you’re just going into the racket sports category, where you go from pickleball to ping pong to tennis to racquetball, you can try different ones within that same category. I think having fun includes aspects of gamification. It could be social activities, things that you enjoy, or just enjoying the aspect of skill development. 

Now, that doesn’t mean that it can’t be frustrating. There are a lot of people who try to acquire new skills, experience, and frustration, but that’s part of the effortful learning process that is good for our brains. Many people avoid things because they’re bad at them, they perceive themselves to be bad at them, or they can anticipate failure. But that’s the idea, and so I have a phrase that I’ve yet to put on a shirt called Embrace the Suck or embrace the sucking at something. I think I probably have recruited more 75-year-old men into Zumba than anyone else, because I’m always pushing this idea that, Hey, you want to embrace the things that you’re avoiding. After all, you suck at them, and that the process of learning is beneficial for your brain.

Heather Sandison, ND

How fun, thank you. From a practical perspective, we talked about you guys in Santa Monica. If somebody is there, go to it. But even though we’re recording this on January 2nd. There are lots of people who have New Year’s resolutions and get them to stick. I always think that for me, it has to be pretty easy. Yes, fun, but also doable. I can’t have this hour-long commute to get there. I can’t overcome this huge hurdle to make it happen. Do you have any other suggestions? Being a fitness guru and expert that you are, how do we get these things to stick to these new habits?

Ryan Glatt

I’m not entirely sure. I just have some ideas. I think that’s the thing: if we try to approach it where we want it to stick and we need to do this thing and keep it a habit forever, we’re already setting ourselves up for failure. I think the first thing is to be honest with ourselves. Who keeps this consistent forever without any speed bumps, and even the professionals? We’re humans as soon as we acknowledge that the journey gets a little bit easier, we don’t have to guilt ourselves or feel bad when we don’t do these things. I think we need to retrain ourselves to have a different relationship with it. That’s the first step. I think the second step is picking things that I think are preferable for people.

We’re just told. We tell other people all the time things they do not prefer. If we go to a restaurant together and say, Hey, here’s all these options; you have to pick one; there’s the overwhelming option; and then there’s me telling you what you should get. then there is you saying, Well, I want that, but I don’t want that. People have a lot of preferences, and I think the first step is just understanding what those preferences are. If I’m trying to get someone to go to a gym because I think it’s a good idea and they don’t want to go, what battle am I fighting here? If I want to help that person exercise online or at home, yes, let’s go down that route. Let’s take the things that people are most likely going to do versus what we think the ideal is. When we start to say, Where are you least likely to fail? Usually, the blanks get filled in pretty easily. When I say, where have you exercised an exercise in the past where it didn’t stick, and where have you exercised in the past where it did stick?

We have a lot of information there, I will stick with the environment. Is it the line, or is it in person? Is it in a gym? Furthermore, are you an internally accountable person, or are you that person who wakes up at 5 a.m. and puts on their running shoes all the time and doesn’t need anybody to tell them? Or are you externally accountable? Do you need a trainer, an accountability person, or a buddy? Do you need a group class? What environment would help you stick to this more? If we start to ask those questions, usually people coach themselves into a program already.

Heather Sandison, ND

Yes, I have a friend who calls himself an accountability buddy.

Ryan Glatt

Yes, accountability. But for some people, I like the idea of that. But for me, that just doesn’t work. You will never catch me in a group exercise class. I’m just too picky. It’s just, okay, everyone’s got their preferences. That’s all. Let’s find it.

Heather Sandison, ND

I’m the opposite. I won’t do it unless I’m in a group; unless it’s social.

Ryan Glatt

I don’t prefer to use phrases like motivation and willpower because I always just assume that this isn’t something someone prefers. I’m okay, let’s package it up in a way you’d like.

Heather Sandison, ND

That’s great. There are so many options that you can usually find a package that works. It’s just a matter of going through the process either on your own or with someone else. But that’s great. I think it’s just some questions to ask yourself. I think you’ve organized that well. I do want to go back to the idea that you have this incredible brain gym, so take us through it. There may be some people who have a group, or they’re in a position where they could recreate something that you have going on. Let’s talk about the ideal, even though by no means are we suggesting that everyone needs this. What does it look like?

Ryan Glatt

Yes. I don’t consider what I do to be ideal. I just consider it a specialty service that isn’t very common. When people are looking to develop an exercise program, we want to check off those three boxes that we laid out: aerobic exercise, strength training, and neuromotor exercise. This dual-tasking, extra gaming, and brain gym stuff is part of that neuro-motor category. Sometimes people want to check that off in this way because it makes sense to them. There’s a good amount of research. More research is always needed. We’re trying to do more of that, but if people were to come into the brain gym, they would spend, let’s say they’ve already had a consultation about their goals and what they’re trying to achieve.

We’ve looked at their physical function; perhaps they’ve had assessments on cognitive function so that there’s a purpose behind what we’re doing, and they may come in for 60 minutes at a time. Usually, sessions are one-on-one, but we do groups as well, and they might start cycling on an exercise bike with a virtual reality headset on, and they can see their hands with no controllers attached to them because of camera technology, and one hand red and one hand’s blue. As they’re pedaling, they’re collecting targets that are of that same color at different levels of motor complexity. By reaching on the same side, crossing across from them, and doing two at the same time, it gets faster and faster. That’s the warm-up. It’s a gamified virtual reality bike.  

Instead of just cycling on the bike and watching the news and thinking, who wants to do that?

Then what we do is go to a big board called the Smart Fit, which has nine different targets. It’s an interactive wall with different lights. They might be going through the alphabet, hitting the letter A, coming up with a word that starts with the letter A while marching in place, and then going on to B. They’re going to Apple, Boy, Cat, Donut, and Eggplant. Maybe I’ll give them a specific category. Then we might do some balance exercises where I give them a sequence of numbers and they’re standing in the middle of a clock face. I say one, three, five, and eight, and then they step on them in the backward order. It’s a whole hour of these different exercises. We go through them in 2 to 3 sets at a time, and we’ll have anywhere from 10 to 15 exercises per session at a physically and mentally challenging activity. 

But I have 95-year-olds with dementia to 52-year-olds with Parkinson’s, and they all get a good challenge. It’s my job to make sure it’s never too much or too little. But before working here five years ago with Dr. David Merrill and the rest of our team, I didn’t have any of this technology, I just had tennis balls and colored dots that I took a Sharpie on and wrote different letters and numbers on them. Inside, I put four of those on the ground. I say, Okay, you got one, two, three, and four dots around you. I’m going to give you a sequence of numbers. I want you to step on it and follow the exact sequence that I give you, or backward while balancing or marching. I’m going to throw you a ball while you do squats, just things that will enhance the cognitive load of that individual.

Now, that’s harder to do on your own. You can’t just get a dual task and give yourself that stimulus. It’s harder to do that. There are a couple of apps that will call out numbers on a clock for you, and you can do extra games. That’s why I suggest that anyone trying to do this on their own without a trainer or technology should just sign up for a dance class or a taichi class because that has enough cognitive load. To be honest, there’s way more research on those things anyway. But I have plenty of people who are doing their resistance training. They’re doing aerobic exercise, they’re taking a tai chi class or a dance class, and they come to see me once a week. Some people have it all, and sometimes people don’t do anything but see me once a week. But every time they see me, I say, Hey, let’s find ways of slowly incorporating other forms of exercise because you need that more regular dosage to potentially have a greater benefit on the brain.

Heather Sandison, ND

What is the ideal amount, or maybe the minimum amount? Is there a range for how much exercise and what types of exercise? Let’s just say you’re starting from zero, and then let’s say you’re somebody who has exercised regularly, but you need to level up.

Ryan Glatt

Yes, for sure. The minimum recommendation that everyone hears is this: 150 minutes. Now, I don’t think anyone measures anything in minutes per week, but somehow, this is the result of this systematic review of literature. It’s 150 minutes a week, and in plain English, it’s about two and a half to five hours a week, or 150 to 300 minutes a week of exercise. two and a half hours to five hours a week. If you break that down, that’s either 30 minutes five times a week or one hour five times a week. There’s a different variation of 45 minutes, 20 minutes, and an hour and a half if you want to break it down that way. 

Most of those minutes refer to cardiovascular activity. But they also say there’s an additional benefit for 2 to 3 days a week of straight training, 2 to 3 days a week of cardiovascular exercise, and 2 to 3 days a week of neuromotor training. But then it can get further confusing because, wait a minute, there’s not nine days in a week,? How do we do all of these different types of exercise while still getting our heart rate up? We’re lifting weights and challenging our brains and bodies. A good way to think about this is multimodal exercise, where let’s say I go to the gym for one hour. I could do 30 minutes of cardio, 30 minutes of straight training, or I could go to a dance class, and most of that dance class is getting my heart rate up. Technically, it’s cardiovascular, and I’m learning a new skill. Now I just checked off two boxes at once, or, let’s say, I’m doing strength training for 30 minutes, and I structure that strength training with minimal rest periods and high-intensity intervals. I’m getting my cardio in my strength training. 

There are a lot of ways to check this off. Now, you don’t need to be checking off all those boxes to elicit health benefits. I often say, Where can we start? In a way, that’s the lowest-hanging fruit. Let’s say an individual’s walking is the most popular activity in the world across all age groups. Usually, when I work with clients, that’s where they’re starting. On a scale of 1 to 10, with 10 being the most intense and 1 being the least intense, how would you rank the intensity of your walking? They might say three to four. I said, Well, for those 150 minutes, we want a four to a six. we’re one point away here. When I phrase it that way, they’re, I’m getting the number of minutes that’s recommended, just not at the intensity. They have to take it from a low intensity to a moderate intensity or greater, or when they’re pedaling on the bike, they’re watching the news and they’re going slow, and they’re not just doing it to do something active. I say, Well if you give yourself a little bit more hits by there and you pedal a little bit faster, you’re checking off that intensity. Maybe you just need to add one or more days per week, and you’re there. You’ve hit the 150 minimum. 

I want to start everyone with that checkbox of 150 minutes per week because 85% or 80% of older adults are not hitting that recommendation. That is the minimum recommendation to achieve a whole host of health benefits. It doesn’t mean anything less than that number isn’t healthy. Anything is healthy. But that’s the minimum dosage that we’re trying to achieve for it to be clinically meaningful across a whole range of health benefits, including brain health. I usually tell people that they are checking off their minutes. If they’re checking off their minute rate, then I look at the variety. Are you just doing cardiovascular activity, or can we add strength training as well? Things like strength training also have a whole host of brain benefits. 

There’s research showing that it can improve the function and structure of the frontal lobe, and I often find many older adults not engaging in strength training for whatever reasons. They don’t know what to do. They’re afraid it will cause injury. They don’t think they need it. They’ve heard that aerobic exercise is the best form for the brain or something in that regard. I start to vary. How many types of exercise modalities can we get if  I’ve never met anyone with what I call the perfect brain-healthy exercise program? I usually find it’s either the number of minutes or the variety. If they’re hitting both the minutes and variety, I start to go by cognitive demand. How much cognitive demand do these things have? Usually, these people need to switch up their routines a little bit. They’ve been doing the same strength training program for several years. Maybe they got a list from a trainer or a physical therapist. They just haven’t changed it. Our brain needs variety to continue to adapt. I usually go through the frequency and duration, then the variety, and then, furthermore, adding some variety and multi.

Heather Sandison, ND

We have a lot of caregivers who attend the summit, and I’m curious if you are a caregiver caring for someone with dementia, either moderate or maybe even going in the direction of more severe. Is there any language that you can help us with in terms of motivating someone? I know you said you don’t use the word motivation, but.

Ryan Glatt

It’s a thing, maybe coaching.

Heather Sandison, ND

Coaching might be a better term in terms of helping and supporting someone in going from maybe almost no exercise, very little movement, maybe a walk to the mailbox, but not much more than that to getting movement.

Ryan Glatt

Yes. That’s a great question. I think there are a lot of potential challenges that can happen when we’re trying to encourage someone with a neurodegenerative condition or neurological condition to exercise. I think the first thing is changing our perspective on how that person approaches it. I work with so many people—so many caregivers or care partners—who say they won’t do it. They’re lazy. I have to explain what amnesic behavior is. Maybe they forget it very well, or perhaps they have apathy. They just aren’t lazy. Usually, these are very accomplished people who, maybe previously, were very highly motivated to do things, but maybe they’re apathetic; maybe it’s a low mood, and so it’s changing the language around how we engage these people. just calling someone lazy and saying, I tried; I told them to do it, and they didn’t do it. That’s usually where most people stop trying. This very much disappoints me because I think it reveals a lack of flexibility in how we approach it. I understand it can be challenging, and people hold on to who that person is, was, or what you have. But I think being flexible and how we approach it are the first steps. 

If we have that mindset of flexibility, we can always problem-solve because there’s always going to be new problems that come up. The second thing is having some language around how this person communicates. I have many clients with neurodegenerative conditions like dementia who will say that when they get tired, they’re in pain. then I ask further, Is this pain or is it fatigue? They’re just describing muscle fatigue, which is a normal response. A normal, or maybe a more reactive, response would be, No, it’s painful. Let’s stop. We stop exercising altogether. so certain bodily sensations and how we communicate around exercise may not be the same either. We might need to be flexible around that as well. Ask clarifying questions; just have them describe it a little bit more. 

Furthermore, if we’re just trying to increase activity, the enjoyment piece is furthermore important for this population because exercise, when adhered to in this population, may not improve cognition as much as in mild cognitive impairment, but can certainly improve mood and physical functioning. When you get someone to exercise in a way that they enjoy, and yes, they’re sleeping better and they’re in a better mood, it’s almost a different person. I think it’s worthwhile trying to figure out how to get that person to engage in this very important activity that is essential for all of us, that allows them to benefit and makes your job easier in your role as a caregiver and care partner. That’s all fine and dandy. But what if they’re just saying, No, I don’t want to exercise? Well, this is where we come back to the internally accountable versus the externally accountable. I think a lot of people are expecting individuals with cognitive impairments to just all of a sudden be internally accountable because someone told them it was important down the line.

I think, especially with more cognitive impairment, we have to outsource that accountability a little bit in a lot of the times when the care partner or caregiver themselves exercises with the person in question. Sometimes that solves the problem because everyone needs it. Everyone’s got to do it at some point. If you are a person caring for a person with dementia and you start exercising with them, sometimes that helps, but sometimes it’s a friend, sometimes it’s hiring a trainer, sometimes it’s a group exercise class, and we just have to find ways of getting people to say yes. Sometimes, if it’s an appointment or something and they dread it and they’re giving you a lot of hard time about it, I don’t want to get up, I don’t want to go. Maybe it’s the time of day; maybe it’s the type of exercise that they’re engaged in. We just have to find that first step to get them to start. Once we get them to start, incorporating other things can be a lot easier.

Heather Sandison, ND

I hear some themes in there. It sounds like you are getting curious, being creative with how to do it, but not stopping. When someone gives you that, No. You’re not committing to the process because there’s a huge upside as a care partner. After all, this person that you’re caring for will become much easier to care for in terms of their mood and their sleep. There are a lot of benefits that we’ll probably see relatively quickly that will make your job so much easier. Putting in that investment of energy and creativity.

Ryan Glatt

If they’re saying, no, it’s not because of them; it’s because of you. If I just said, Dr. Sandison, we’re going to dinner tonight, and you say, no, I probably should have asked it as a question. People still need their autonomy. I think that doesn’t go away.

Heather Sandison, ND

Yes, I got it. That’s helpful. You also mentioned, Dance, Dance Revolution, and your experience with that and the Nintendo Wii. I can imagine some people are sitting at home. I think we have one of those in the basement that should be dusted off. Can you speak to that? First of all, are these even available, so somebody wants to buy one? Can they get one?

Ryan Glatt

You can go and try to buy a Nintendo Wii now, but it can be incredibly difficult and expensive. Furthermore, they’re not being supported. I don’t think that I’ve got three Nintendo Wii’s from clients who asked to fix this, and it might just be time to move on. If you have a functioning one and you want to use it, that’s fine. There was an article I was reading about a Bowling League, a Senior Wii Bowling League, where they had over 300 seniors in Texas competing in Wii Bowling still, which is very incredible. Since then, Nintendo has moved on to other things, and getting a Dance, Dance Revolution set up is challenging to do, even for people like myself.

I think it’s important to ask: is that necessary, is that something we want to do, or is there a way to get that in a different physical and cognitive stimulation, in a different manner? If it was dancing, then maybe just take a dance class. However, some technologies use augmented reality on your phone camera or on your laptop to track your body movements without controllers. Then also there are some devices coming out that use this camera technology things as the Nintendo Switch. 

However, my cautionary take is that for older adults and their families, the technology, the hardware, and the software can often be a barrier. There’s nothing magical or that’s a secret ingredient of these games, extra games that we have to capture that specific thing. It’s whatever works best. If I find myself at the point where I have to walk people through the technical aspects of an app or its hardware, we’re already too far there. It’s not so worthwhile. It’s what it represents, which is that simultaneous cognitive and physical demand. The question is, well, in what way would that serve you? If it’s Nintendo? We are biased. Well, we can go down that route. But even for people who are passionate about extra gaming, that’s not it.

Heather Sandison, ND

YouTube, just other options, from the comfort of your home, which is, I think, what’s appealing about that option. YouTube and Zoom would give you access to, I’m sure, many dual-task YouTube videos out there. I’ve seen some, but I don’t know if there’s any.

Ryan Glatt

Not as many as you would think. Then the question is, are they good? Well, that is good for whom? Did they do them according to the research? There are some YouTube videos, but none specifically that I could recommend. Some technologies are coming out that you just download onto your computer or iPad, and they’re games specifically designed for older adults where you’re stepping left and in your, you’re playing games you would on the Nintendo Wii. Dual tasking is once again a naturally available and skill-based activity. The reason for skill-based activities is that games will always expire. There will always be the next thing. You’ll always run out of numbers to count from before getting bored and just being like, Why am I doing this? But you’ll never run out of skill-development opportunities. It’s interesting because skill-based activities in theater, even things in theater arts, can all improve cognition through a common process, which is the cognitive demands that come with skill acquisition. 

It’s less likely that these extra games and dual tasks are beneficial just because of a secret sauce. What’s more, these are novel skills. Anytime I play a new game. There’s a set of skills that needs to be developed. Skill acquisition is what we’re after here. So skill acquisition can be acquired in a gaming environment, it can be acquired in a rehab environment, or it can be acquired on your own. Sometimes developing a strength training program is a skill that needs to be acquired and further developed. There’s never a sport that has a ceiling or a limit unless you’re good at that sport. But even people who have been playing that sport forever, if we transfer sport, if I take a tennis player, a pro tennis player, I’ll have people that used to play pro sports and put them in a Tai Chi class. It’s a different skill, and now we’re adding that variety. I think when it comes to brain health and exercise, we’re looking to have enough predictability and preferences to be consistent. But on the other side of that, there is enough variety to keep our brains plastic when learning.

Heather Sandison, ND

In terms of resources, you guys offer Zoom classes, and I can imagine. 

Ryan Glatt

We do. Yes. 

Heather Sandison, ND

There are people out there who are, well, I just don’t know. You’ve given me a lot of information, but I just want somebody to hold my hand through getting into this and help me figure out what’s appropriate for me. Do you offer that thing? If so, do you find out more?

Ryan Glatt

Yes. The first thing I recommend is that I spend the vast majority of my time convincing people, specifically, that what we do is not for them. The reason I do it is because, yes, there is some exciting evidence for what we do, but there is more evidence on the benefits of other types of exercise that are more accessible to you for a variety of reasons. The reason I do that is because if the idea is to develop a lifestyle, we’re not trying to create a dependency on these technologies or what we do here. We’re just filling a gap in what doesn’t exist now, but that doesn’t mean that’s the most important thing. I spend a lot of my time doing that to empower people to have their program that they can do multiple days per week for the rest of their lives. I think that’s the most important thing to be realistic about. 

The second thing is that we’re developing ways of expanding and how we can get this out there because, as you can hear from my hemming and hawing, it’s not as accessible as it should be based on the available evidence. We’re developing games to do this over Zoom, and we’ll be piloting some of that with Marama, for instance, which we’re very excited about. We’re also doing some research studies to increase our understanding of how this could benefit people. There are also some apps out there like Clock Yourself, which is a clock that can call out numbers that you can imagine on the ground or the wall. There’s another one called SwitchedOn that will show you arrows and numbers. Now, some of these apps, if you try to figure out how to use them, aren’t worth the trouble; just take a dance class, by all means.

There are other programs; there’s one called LudoFit, which is the one that uses your webcam to track your body movements. Of course, these are not appropriate for everybody, but we do offer health coaching, brain health coaching to help customize and create these exercise programs, and also other plans around sleep and nutrition, mindfulness, and cognitive training to help people develop a comprehensive, brain-healthy lifestyle program, which I know is also amazing work that you’re doing as well. Individuals who just want to develop an exercise program can follow some of the guidelines because I will have a broken record, but I will help people customize that and think through it further. Then we do offer in-person services and over Zoom as well.

Heather Sandison, ND

Then you started to allude to this, but how can this precision medicine model be combined with exercise? What you see, I know you guys see Dyads, so care partners with persons who are suffering from dementia as well as people with mild cognitive impairment. You’ve seen a lot of iterations of people come through. What’s the ideal way to combine this with the medicine side?

Ryan Glatt

A precision medicine approach to exercise would be based on certain biomarkers or available data based on your AP status, based on blood work, or based on brain imaging to further customize an exercise program. If we have a DEXA scan, I see that there’s not enough lean mass, and I’m also seeing that maybe there’s some frontal lobe atrophy or executive functioning deficits. Then I’m also seeing maybe some underweight people. Those are all three data points that may point to resistance training and say, Hey, maybe we need to do more of that. Or maybe there’s someone with cerebellar atrophy. It’s not to the extent where there’s a diagnosis, but it’s just a trend on their MRI. Then they’re experiencing some other types of executive functioning challenges, such as working memory, and they’re having some balance deficits. Well, guess what? We just recommended you take a dance class for those three things. I think precision medicine will help us further what we call exercise prescription. Just as we would diet and modify some things based on blood markers and things of that regard, we would exercise.

Heather Sandison, ND

Nice. You are on track to have a PhD. Will you give everybody an update on what your thesis is and what it is that you’re working on?

Ryan Glatt

I haven’t fully decided on a thesis, but I better hurry up and do that because this is the year when I start it. My main thesis is to look at a feasibility study looking at the feasibility, which is adherence, safety, and the user experience surrounding these new games that I’ve had the pleasure of developing here. I, with the great grateful patients that we’ve had and some generous donors to develop some games, which we’ve done to provide over Zoom, as well as the ability to send someone a link with no log-on, they just click it and they have these exercises and cognitive stimuli on their computer. They don’t have to mess with cameras, controllers, or any technology, just their browser, and they’re playing these brain-body games without any of that. I’m looking at the feasibility of these games, both supervised with me delivering them as well as for individuals using them on their own, specifically individuals with mild cognitive impairment, and seeing if it’s safe, is it feasible, and is it acceptable as an enjoyable activity? probably something in that line of thinking.

Heather Sandison, ND

Fantastic. Well, we are going to put the Pacific Neuroscience Institute, which is where Ryan is currently coaching.

Ryan Glatt

Specifically the Pacific Neuroscience Institute Lifestyle Program. The pacificneuroscienceinstitute.org is the place to reach me.

Heather Sandison, ND

That’s exactly what we’re looking for, pacificneuroscienceinstitute.org is where to find out more about Ryan and what they’re doing at the Pacific Neuroscience Institute there. Ryan, we are just so delighted and excited to start working with you and collaborating with you at Marama. We’re going to have Ryan and some of the people on his team do these pilot studies. Maybe you can say that more eloquently than I want to know.

Ryan Glatt

We’re excited to deliver a.

Heather Sandison, ND

Lecture collection for your thesis.

Ryan Glatt

Yes, you are not. You would know about that, but we do. Well, maybe we can discuss that, but we are looking at delivering some virtual dual-task exercise programs over Zoom for a group of your residents, as well as some customized group brain training and memory techniques, which are two separate classes that will be piloting at Marama.

Heather Sandison, ND

We’re looking forward to doing that, and it’s just such a privilege to be collaborating with you guys. There’s so much science. You guys are just highly credible. There’s amazing stuff going on there, and I so appreciate the work you’re doing to help people figure out how they can get the most out of exercise for their brains. Thank you.

Ryan Glatt

Likewise. Thank you so much for the opportunity.